A quality survey of electronic medical record in mental health special hospital

Objective:To investigate the quality difference between electronic medical record and traditional handwritten medical record in the mental health specialty hospital.Method:342 discharged medical records from August 1st,2009 to October 31st,2009 were randomly selected,including 160 electronic medical records(electronic medical record group) and 182 traditional handwritten medical records(handwritten medical record group).Every discharged medical record was assessed according to the basic criterion for handwriting of medical record in Shanghai mental health specialty.The information was compared between the two groups,including the total score of the medical record,time in hospital,times of hospitalization,whether or not fill in all items in medical record and whether or not the same diagnosis for admission and discharge.Results:There was no significant difference in the score between electronic medical record group and handwritten medical record group(98.1±1.7) vs(98.0±1.6),(t=0.450,df=340,P=0.65).Correlated analysis between the score of medical record and the time in hospital showed that the score of medical record was negatively related to the time in hospital(r=-0.108,P=0.046).Sub-group analysis suggested that the score of electronic medical record was negatively related to the time in hospital(r=-0.161,P=0.042),while there was no correlation between the score of traditional handwritten medical record and the time in hospital(r=-0.032,P=0.336).Conclusion:There was no significant difference in the quality between electronic medical record and traditional handwritten medical record.However,the quality of medical record was negatively related to the time in hospital.